ABSTRACT Objective Consequently, in this study, we aimed to evaluate 1,203 cases of referral to a quaternary vascular surgical service, in São Paulo, Brazil, over a 6-year period, to assess the appropriate need for referral; in addition to the prevalence of surgical indications. Methods In this retrospective analysis, we reviewed the institutional records of participants referred from Basic Healthcare Units to a vascular surgical service inside the Brazilian Unified Health System, between May 2015 and December 2020. Demographic and clinical data were collected. The participants were stratified, as per the reason for referral to the vascular surgical service, previous imaging studies, and surgical treatment indications. Referral appropriateness and complementary examinations were evaluated for each disease cohort. Finally, the prevalence of cases requiring surgical treatment was defined as the outcome measure. Results Of the 1,203 referrals evaluated, venous disease was the main reason for referral (53%), followed by peripheral arterial disease (19.4%). A considerable proportion of participants had been referred without complementary imaging or after a long duration of undergoing an examination. Referrals were regarded as inappropriate in 517 (43%) cases. Of these, 32 cases (6.2%) had been referred to the vascular surgical service, as the incorrect specialty. The percentage of referred participants who ultimately underwent surgical treatment was 39.92%. Carotid (18%) and peripheral arterial diseases (18.4%) were correlated with a lower prevalence of surgical treatments. Conclusion The rate of referral appropriateness to specialized vascular care from primary care settings was low. This may represent a subutilization of quaternary surgical services, with low rates of surgical treatment.

Abstract Background and objective: Lower limb varicose veins are a prevalent disease associated with several available treatment options, including conventional surgery and polidocanol foam sclerotherapy. However, few studies have analyzed therapeutic modality outcomes based on Patient-Reported Outcome Measures (PROMs). This large sample-size study was designed to evaluate the outcomes of polidocanol foam sclerotherapy compared to conventional surgery based on an analysis of PROMs. Methods: This was a prospective, observational, and qualitative study of 205 patients who underwent varicose vein treatment with either polidocanol foam sclerotherapy (57 patients, 90 legs) or conventional surgery (148 patients, 236 legs). Patients were preoperatively assessed and re-evaluated 30 days after the procedure using the Venous Disease Severity Score (VCSS) and specific venous disease quality-of-life questionnaires (VEINES-QoL/Sym). Results: Both treatments significantly improved VCSS and VEINES results 30 days after the procedure (p < 0.05). However, surgery promoted greater improvements in VCSS (on average 4.02-points improvement, p < 0.001), VEINES-QoL (average 8-points improvement, p < 0.001), and VEINES-Sym (average 11.66 points improvement, p < 0.001) than did sclerotherapy. Postoperative pain and aesthetic concerns about the legs were the domains of the questionnaires in which the results varied the most between the treatment modalities, with worse results for sclerotherapy. Conclusion: Both polidocanol foam sclerotherapy and conventional surgery positively impact patients’ quality of life after 30 days, but the improvement is more significant for patients who undergo conventional surgery.

RESUMO As fraturas articulares distais da perna estão entre as fraturas mais comuns do ser humano ao longo de todas as faixas etárias, e 50% delas necessitam de tratamento cirúrgico. Existem poucos trabalhos discutindo a epidemiologia e os custos dessa fratura na literatura mundial e, principalmente, na nacional. Objetivo: Avaliar a incidência anual e o valor de reembolso das fraturas distais da perna com indicação para tratamento cirúrgico entre os anos de 2008 e 2021. Métodos: Estudo retrospectivo para analisar os dados complexos estruturados de alto volume e alta variabilidade (Big Data), disponibilizados publicamente na plataforma TabNet (Datasus), através de um software com inteligência artificial. Foram analisados os dados de 2008 a 2021 do tratamento cirúrgico de fratura maleolar, fratura distal da tíbia e fratura isolada da fíbula. Resultados: Entre 2008 e 2021, houve incidência média de 28,8 fraturas/105 habitantes-ano, representando 14,62% de todas as fraturas. O valor total pago pelas internações dessas fraturas foi de R$ 34.218.014,62 ao longo desses 14 anos. Conclusão: A incidência das fraturas articulares distais da perna acompanha o padrão daqueles registrados em outros países. O reajuste do repasse ao longo dos anos foi inferior à inflação acumulada. Nível de Evidência II, Análises Econômicas e de Decisão - Desenvolvimento de Modelo Econômico ou de Decisão.

ABSTRACT The distal leg joint fractures are among the most common fractures in humans across all age groups, and 50% of them require surgical treatment. Few studies discuss the epidemiology and costs of this fracture in the global and national literature. Objective: To evaluate the annual incidence and reimbursement value of distal leg joint fractures requiring surgical treatment from 2008 to 2021. Methods: A retrospective study was conducted to analyze the complex structured data of high volume and high variability (Big Data), publicly available on the TabNet platform (DATASUS), via software with artificial intelligence. Data from 2008 to 2021 on surgical treatment for malleolar fracture, distal tibia fracture, and isolated fibula fracture were analyzed. Results: From 2008 to 2021, there was an average incidence of 28.8 fractures/105 inhabitants per year, representing 14.62% of all fractures. The total amount paid for hospitalizations due to these fractures was R$ 34,218,014.62 over these 14 years. Conclusion: The incidence of distal leg joint fractures follows the pattern of those recorded in other countries. The adjustment of reimbursement over the years was lower than the accumulated inflation. Level of Evidence II, Economic and Decision Analyses - Developing an Economic or Decision Model.

Abstract BACKGROUND: Endoscopic thoracic sympathectomy is the definitive surgical treatment for hyperhidrosis and a nationwide study has suggested that cultural and socioeconomic factors play a role in the numbers of operations performed. Thus, there is a need to evaluate local data in order to understand the local epidemiology and trends in hyperhidrosis treatment. OBJECTIVE: To study the epidemiology of sympathectomy for treating hyperhidrosis in São Paulo, the largest city in Brazil. DESIGN AND SETTING: Population-based retrospective cross-sectional study. METHODS: Data on sympathectomies for treating hyperhidrosis between 2008 and 2018 were assessed from the database of the Municipal Health Department of São Paulo, Brazil. RESULTS: 65.29% of the patients were female, 66.2% were aged between 20 and 39 years and 37.59% had registered with addresses outside São Paulo. 1,216 procedures were performed in the city of São Paulo from 2008 to 2018, and 78.45% of them were in only two public hospitals. The number of procedures significantly declined over the years (P = 0.001). 71.63% of the procedures were associated with 2-3 days of hospital stay, only 78 intensive care unit days were billed and we did not observe any intra-hospital death. CONCLUSION: The profile of patients operated on in São Paulo (young women) is similar to that described in other populations. Sympathectomy is a very safe procedure, with no mortality in our series. There was a decreasing trend in the number of surgeries over the years.

ABSTRACT Introduction: Although endovascular correction is a promising perspective, the gold-standard treatment for thoracoabdominal aortic aneurisms and type-B dissections with visceral involvement remains open surgery, particularly due to its well-established long-term durability. This study aims to describe and evaluate public data from patients treated for thoracoabdominal aortic aneurism in the Brazilian public health system in a 12-year interval. Methods: Data from procedures performed between 2008 and 2019 were extracted from the national public database (Departamento de Informática do Sistema Único de Saúde, or DATASUS) using web scraping techniques. Procedures were evaluated regarding the yearly frequency of elective or urgency surgeries, in-hospital mortality, and governmental costs. All tests were done with a level of significance P<0.05. Results: A total of 812 procedures were analyzed. Of all surgeries, 67.98% were elective cases. There were 328 in-hospital deaths (mortality of 40.39%). In-hospital mortality was lower in elective procedures (26.92%) than in urgency procedures (46.74%) (P=0.008). Total governmental expenditure was $3.127.051,56 — an average of $3.774,22 for elective surgery and $3.791,93 for emergency surgery (P=0.999). Conclusion: The proportion of urgency procedures is higher than that recommended by international literature. Mortality was higher for urgent admissions, although governmental costs were equal for elective and urgent procedures; specialized referral centers should be considered by health policy makers.

Abstract BACKGROUND: Primary hyperhidrosis is a condition characterized by excessive sweating, inconsistent with the needs for thermoregulation. OBJECTIVE: To assess the effectiveness and the change in the quality of life of patients undergoing bilateral VATS (video-assisted thoracoscopic sympathectomy) for treatment of hyperhidrosis, in a large case series. DESIGN AND SETTING: Cohort study conducted in a tertiary hospital specializing in hyperhidrosis located in São Paulo, Brazil. METHODS: A total of 2,431 patients who underwent surgery consisting of bilateral video-assisted thoracoscopic sympathectomy between January 2000 and February 2017 were retrospectively assessed in an outpatient clinic specializing in hyperhidrosis. The patients underwent clinical and quality of life assessments on two occasions: firstly, prior to surgery, and subsequently, one month after the operation. The presence or absence of compensatory hyperhidrosis (CH) and general satisfaction after the first postoperative month were also evaluated. RESULTS: All the patients operated had poor or very poor quality of life before surgery. In the postoperative period, an improvement in the quality of life was observed in more than 90% of the patients. Only 10.7% of the patients did not present CH, and severe CH occurred in 22.1% of the patients in this sample. CONCLUSION: Bilateral VATS is a therapeutic method that decreases the degree of sweating more than 90% of patients with palmar and axillary hyperhidrosis. It improves the quality of life for more than 90% of the patients, at the expense of development of CH in approximately 90% of the patients, but not intensely.

ABSTRACT Objective Despite the development of endovascular procedures, open repair remains the gold standard for the treatment of aortic thoracoabdominal aneurysms and some type B dissections, with well-established good outcomes and long-term durability at high-volume centers. The present study described and analyzed public data from patients treated in the public system in a 12-year interval, in a city where more than 5 million inhabitants depend on the Public Health System. Methods Public data from procedures performed between 2008 and 2019 were extracted using web scraping techniques. The variables available in the database include sex, age, elective or emergency hospital admission, number of surgeries, in-hospital mortality, length of stay, and information on reimbursement values. Results A total of 556 procedures were analyzed. Of these, 60.79% patients were men, and 41.18% were 65 years of age or older. Approximately 60% had a residential address registered in the municipality. Of all surgeries, 65.83% were elective cases. There were 178 in-hospital deaths (mortality of 32%). In the elective context, there were 98 deaths 26.78% versus 80 deaths (42.10%) in the emergency context (p=0.174). Mortality was lower in the hospitals that performed more surgeries. A total of USD 3,038,753.92 was paid, an average of USD 5,406.95 for elective surgery and USD 5,074.76 for emergency surgery (p=0.536). Conclusion Mortality was no different between groups, and hospitals with higher volume presented more favorable outcomes. Specialized referral centers should be considered by health policy makers.

Abstract BACKGROUND: Endoscopic thoracic sympathectomy is the definitive surgical treatment for hyperhidrosis and a nationwide study has suggested that cultural and socioeconomic factors play a role in the numbers of operations performed. Thus, there is a need to evaluate local data in order to understand the local epidemiology and trends in hyperhidrosis treatment. OBJECTIVE: To study the epidemiology of sympathectomy for treating hyperhidrosis in São Paulo, the largest city in Brazil. DESIGN AND SETTING: Population-based retrospective cross-sectional study. METHODS: Data on sympathectomies for treating hyperhidrosis between 2008 and 2018 were assessed from the database of the Municipal Health Department of São Paulo, Brazil. RESULTS: 65.29% of the patients were female, 66.2% were aged between 20 and 39 years and 37.59% had registered with addresses outside São Paulo. 1,216 procedures were performed in the city of São Paulo from 2008 to 2018, and 78.45% of them were in only two public hospitals. The number of procedures significantly declined over the years (P = 0.001). 71.63% of the procedures were associated with 2-3 days of hospital stay, only 78 intensive care unit days were billed and we did not observe any intra-hospital death. CONCLUSION: The profile of patients operated on in São Paulo (young women) is similar to that described in other populations. Sympathectomy is a very safe procedure, with no mortality in our series. There was a decreasing trend in the number of surgeries over the years.

SUMMARY OBJECTIVES: The aim of this study was to evaluate the epidemiology of varicose vein stripping in Brazil’s largest city, São Paulo. METHODS: Open and anonymous data regarding varicose vein surgeries between 2008 and 2018 were evaluated from the TabNet platform of the Municipal Health Secretary of São Paulo, Brazil. RESULTS: Most patients were female and adults. A total of 66,577 varicose vein surgeries were performed in public hospitals and outpatient clinics in São Paulo, with a statistically significant increase for both unilateral (p=0.003) and bilateral (p<0.001) procedures. Since 2016, unilateral procedures have been performed more frequently than bilateral procedures. Most procedures were associated with same-day (54.8%) or next-day (32%) discharge. The in-hospital mortality rate was 0.0045%. The total amount reimbursed was $20,693,437.94, corresponding to a mean value of $310.82 per procedure. CONCLUSION: Surgeries to treat chronic vein disease totaled 66,577 in 11 years, demanding $20,693,437.94 from the public health system. The majority of treated patients were female, over 40 years of age, and local residents. Procedure rates have increased over the years. The in-hospital mortality rate was very low (0.0045%).

Resumo Contexto No Brasil, a mortalidade por aneurisma de aorta aumentou 16,8% de 1990 a 2015. São Paulo é a maior cidade do Brasil, e cerca de 5 milhões de pessoas dependem do sistema público de saúde. Objetivos Análise epidemiológica das cirurgias do aneurisma de aorta abdominal na cidade de São Paulo. Métodos As cirurgias para correção do aneurisma de aorta infrarrenal realizadas no período de uma década (de 2008 a 2017) foram estudadas utilizando-se plataformas publicamente disponíveis do Sistema Único de Saúde e do Departamento de Informática do Sistema Único de Saúde. Resultados Foram analisados 2.693 procedimentos, entre os quais 66,73% eram endovasculares. Entre os pacientes, houve predominância do sexo masculino (78,7%) e daqueles com 65 anos ou mais (70,7%). Um total de 64,02% eram admissões hospitalares eletivas. Ocorreram 288 óbitos hospitalares (mortalidade: 10,69%). A mortalidade durante a internação foi menor para cirurgia endovascular do que para cirurgia aberta tanto no contexto eletivo (4,13% versus 14,42%) quanto urgente (9,73% versus 27,94%) (p = 0,019). O maior volume (n = 635) apresentou menor mortalidade intra-hospitalar (3,31%). Foi pago um total de $24.835.604,84, sendo uma média de $2.318,63 para cirurgia abertura eletiva, $3.420,10 para cirurgia abertura de emergência, $12.157,35 para cirurgia endovascular eletiva e $12.969,12 para cirurgia endovascular na urgência. Os custos dos procedimentos endovasculares foram estatisticamente superiores aos valores pagos para as cirurgias abertas (p < 0,001). Conclusões Foram realizadas duas vezes mais cirurgias endovasculares do que abertas, as quais apresentaram menor tempo de internação e menor mortalidade.

Abstract Background From 1990 to 2015, mortality from aortic aneurysms increased 16.8% in Brazil. São Paulo is the largest city in Brazil and about 5 million people depend on the public health system there. Objectives To conduct an epidemiological analysis of abdominal aortic aneurysm surgeries in the city of São Paulo. Methods Infra-renal aortic aneurysm procedures performed over a decade (from 2008 to 2017) were studied using publicly-available platforms from the Unified Health System and DATASUS. Results 2693 procedures were analyzed; 66.73% were endovascular; 78.7% of patients were male; 70.7% were aged 65 years or more; 64.02% were elective hospital admissions. There were 288 in-hospital deaths (mortality: 10.69%). In-hospital mortality was lower for endovascular surgery than for open surgery; both for elective (4.13% versus 14.42%) and urgent (9.73% versus 27.94%) (p = 0.019) admissions. The highest volume hospital (n = 635) had the lowest in-hospital mortality (3.31%). USD 24,835,604.84 was paid; an average of $ 2,318.63 for elective open, $ 3,420.10 for emergency open, $ 12,157.35 for elective endovascular and $ 12,969.12 for urgent endovascular procedures. Endovascular procedure costs were statistically higher than the values paid for open surgeries (p <0.001). Conclusions Endovascular surgeries were performed twice as often as open surgeries; they had shorter hospital stays and lower mortality.

Resumo Contexto A doença arterial periférica (DAP) é uma doença com alta morbidade global, afetando mais de 200 milhões de pessoas. Objetivos Neste estudo, analisamos o tratamento cirúrgico para DAP no sistema público de saúde do Brasil no período de 12 anos, com base em dados publicamente disponíveis. Métodos O estudo foi conduzido a partir da análise de dados disponíveis na plataforma do Departamento de Informática do Sistema Único de Saúde (DATASUS), do Ministério da Saúde, avaliando a distribuição da técnica cirúrgica utilizada, a mortalidade e o custo ao longo dos anos. Resultados Um total de 129.424 procedimentos foram analisados (para claudicantes e isquemia crítica, em proporção desconhecida). A maiora dos procedimentos foi via endovascular (65,49%), com tendência de aumento nessa desproporção (p < 0,001). Houve 3.306 mortes intra-hospitalares (mortalidade de 2,55%) com menor mortalidade no grupo endovascular (1,2% vs. 5,0%; p = 0,008). O investimento governamental total para esses procedimentos foi de US$ 238.010.096,51, e os procedimentos endovasculares foram significativamente mais caros que a cirurgia aberta convencional (US$ 1.932,27 vs. US$ 1.517,32; p = 0,016). Conclusões No sistema público de saúde brasileiro, as revascularizações de membros inferiores ocorreram com frequência crescente entre 2008 e 2019. Os procedimentos endovasculares foram mais comuns e relacionados a menor mortalidade intra-hospitalar, mas a maiores custos.

Abstract Background Worldwide, peripheral arterial disease (PAD) is a disorder with high morbidity, affecting more than 200 million people. Objectives Our objective was to analyze surgical treatment for PAD provided on the Brazilian Public Healthcare System over 12 years using publicly available data. Methods The study was conducted with analysis of data available on the Brazilian Health Ministry’s database platform, assessing distributions of procedures and techniques over the years and their associated mortality and costs. Results A total of 129,424 procedures were analyzed (performed either for claudication or critical ischemia, proportion unknown). The vast majority of procedures were endovascular (65.49%) and this disproportion exhibited a rising trend (p<0.001). There were 3,306 in-hospital deaths (mortality of 2.55%), with lower mortality in the endovascular group (1.2% vs. 5.0%, p=0.008). The overall governmental expenditure on these procedures was U$ 238,010,096.51, and endovascular procedures were on average significantly more expensive than open surgery (U$ 1,932.27 vs. U$ 1,517.32; p=0.016). Conclusions Lower limb revascularizations were performed on the Brazilian Public Healthcare System with gradually increasing frequency from 2008 to 2019. Endovascular procedures were vastly more common and were associated with lower in-hospital mortality rates, but higher procedure costs.

SUMMARY OBJECTIVE: This study examines the changes in anxiety and depression scores of 84 patients subjected to aortic or iliac aneurysm correction with no previous psychiatric history. METHODS: Patients were referred to the evaluation using the Beck Anxiety and Depression Inventories no more than 3 days before surgery (i.e., preoperative [Pre-Op]), 30 days after revascularization (i.e., Early postoperative [PO]), and at least 6 months after revascularization (i.e., Late PO). RESULTS: Mean anxiety scores declined from baseline at both the Early (mean difference: 2.75, p<0.001) and Late PO (mean difference: 2.74, p=0.001). The depression levels showed no significant variation in either evaluation (Early PO; mean difference: −0.84, p>0.05, Late PO: 0.87, p=0.05). A more severe degree of anxiety at baseline was related to better anxiety results both in the Early PO (p=0.041) and Late PO (p=0.008). An endovascular technique was related to the improvement in depression symptoms in the Early PO (p=0.01) but the worsening of the symptoms in the Late PO (p=0.033). CONCLUSIONS: Patients subjected to aortoiliac aneurysm corrections have a higher incidence of anxiety and depressive symptoms. Anxiety symptoms, but not the depressive ones, improved considerably following the successful treatment. The formal psychiatric evaluation may be beneficial for patients with less improvement in the symptom.

OBJECTIVES: Studies have identified correlations between the psychological characteristics of individuals with primary hyperhidrosis (HH), the degree of sweating, and the quality of life (QoL). This study aimed to evaluate the prevalence of anxiety and depression symptoms in patients with HH before and after oxybutynin treatment. METHODS: Data were collected from 81 patients. Palmar or axillary HH was the most frequent complaint (84.0%). All patients were evaluated before the medication was prescribed and after five weeks of treatment. The Beck Depression Inventory and Beck Anxiety Inventory were used to evaluate depression and anxiety. RESULTS: Improvement in HH occurred in 58 patients (71.6%), but there was no improvement in 23 patients (28.4%). The QoL before treatment in all patients was either “poor” or “very poor.” Patients who experienced improvement in sweating rates also experienced a greater improvement in QoL than patients who did not experience improvement in sweating at the main site (87.9% vs. 34.7%) (p<0.001). A total of 19.7% of patients showed an improvement in their level of depression, and a total of 46.9% of patients exhibited improvements in their level of anxiety. A significant correlation was observed between sweating and anxiety (p=0.015). CONCLUSION: Patients with HH who experienced improvements in sweating immediately after treatment with oxybutynin exhibited small improvements in their levels of depression and significant improvements in their levels of anxiety and QoL.

OBJECTIVES: In Brazil, descending thoracic aorta disease, including aneurysms and dissections, is managed preferentially by endovascular treatment, owing to its feasibility and good results. In this study, we analyzed endovascular treatment of isolated descending thoracic aortic disease cases in the Brazilian public health system over a 12-year period. METHODS: Public data from procedures performed from 2008 to 2019 were extracted using web scraping techniques to assess procedure type frequency (elective or urgency), mortality, and governmental costs. RESULTS: A total of 5,595 procedures were analyzed, the vast majority of which were urgent procedures (61.82% vs. 38.18%). In-hospital mortality was lower for elective than for urgent surgeries (4.96 vs.10.32% p=0.008). An average of R$16,845.86 and R$20,012.04 was paid per elective and emergency procedure, respectively, with no statistical difference (p=0.095). CONCLUSION: Elective procedures were associated with lower mortality than urgent procedures. There was no statistically significant difference between elective and urgent procedures regarding costs.

OBJECTIVES: In Brazil, descending thoracic aorta disease (TAD), including aneurysms and dissection, are preferentially managed by endovascular treatment (TEVAR) due to the feasibility and good results of this technique. In this study, we analyzed endovascular treatment of isolated TAD (ITAD) in the public health system over a 10-year period in São Paulo, a municipality in Brazil in which more than 5 million inhabitants depend on the governmental health system. METHODS: Public data from procedures performed between 2008 and 2019 were extracted using web scraping techniques. The following types of data were analyzed: demographic data, operative technique, elective or urgent status, number of surgeries, in-hospital mortality, length of hospital stay, mean length of stay in the intensive care unit, and reimbursement values paid by the government. Trauma cases and congenital diseases were excluded. RESULTS: A total of 1,344 procedures were analyzed; most patients were male and aged ≥65 years. Most individuals had a residential address registered in the city. Approximately one-third of all surgeries were urgent cases. There were 128 in-hospital deaths (9.52%), and in-hospital mortality was lower for elective than for urgent surgeries (7.29% vs. 14.31%, p=0.031). A total of R$ 24.766.008,61 was paid; an average of R$ 17.222,98 per elective procedure and R$ 18.558,68 per urgent procedure. Urgent procedures were significantly more expensive than elective surgeries (p=0.029). CONCLUSION: Over a 10-year period, the total cost of ITAD interventions was R$ 24.766.008,61, which was paid from the governmental system. Elective procedures were associated with lower mortality and lower investment from the health system when compared to those performed in an urgent scenario.